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Friday, April 2, 2010

Whose costs are we talking about?

It is said that economics is the study of the allocation of scarce resources. Scarcity touches basically everything in the human realm since there are never sufficient resources to fulfill all legitimate wants, even in the realm of health care. The question becomes, how do we deal with scarcity in any human realm and in particular health care?

Dr. Molly Cooke has authored a commentary in a recent NEJM entitled, "Cost Consciousness in Patient Care — What Is Medical Education’s Responsibility?

On the whole I agree with Dr. Cooke that cost considerations need to considered at multiple levels of decision making and awareness of true costs by all parties is the first step in avoiding waste of scarce resources. However, beyond that realm of agreement  our perspective diverge. One reason for the divergence is based upon the lack of precision in terms of what Dr. Cooke means by cost. When addressing cost the term has no meaning unless one defines cost to who or what. Using cost without a definition of who the actual bearer of the cost will be is meaningless, much like saying 50% larger or 30% better without giving some reference for comparison. 

The whole concept of cost makes sense when specific entities are weighing investment of resources and balancing investment in one domain vs. another. Investments may be expensive but deemed worth the cost given the benefits conferred. Thus, there lies the rub. In the present system of resources made common in order to confer benefits upon specific individuals, Dr. Cooke is asking physicians to alter their historical role as patient advocates and jettison this in order to become an advocate of some other entity championing the common good. 
Second, we must abandon the myth of the physician as single-minded advocate for any amount of benefit for every patient. We make all kinds of choices in caring for patients; some involve denying care that patients perceive as — and that might actually be — beneficial.

Furthermore, in order to train the next generation of physicians to become the instruments to impose her vision of cost control, we need to incorporate the concept of divided allegiance into our medical school curriculum. 
I have no doubt that Dr. Cooke is motivated by the highest ethical standards and she has devoted her life to a very noble calling of medical education. However, I am not sure she understands the slippery slope that she has ventured on to. Is she willing to make such a divided allegiance completely transparent to her patients, placing it upon flyers, stating clearly that "I am not your single minded advocate". 

As I see it, we have a simple choice. When we commonize more and more resources, those who make decisions regarding their allocation become less and less beholden to patients and more and more beholden to those who control those resources. We as physicians will respond more and more to external metrics conceived by those arms length (or farther) from patient wants, driven by the desire to prevent the tragedy of the commons. This will follow as a consequence of commonizing the resources used to provide health care and is completely and utterly unavoidable. When we chose this pathway, the end result is virtually certain that the doctor patient relationship is forever changed. Lessons from history also suggest that commonized resources are often squandered as well.

The alternative choice is to avoid commonizing resources whenever possible, leaving resources in the hands of potential patients who will be more attuned to consumption of their private resources. This pathway decentralizes the responsibility for cost control, placing it at grass roots level. When patients pay for care, they constantly serve as teachers for their caring providers, letting them know when the cost appears to be out of line. Markets work like that.

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